<script>
  $().ready(function() {
    $("#rfc"           ).mask("aaaa999999***"   );
    $("#fnac"          ).mask("9999-99-99"      );
    $("#telefono"      ).mask("(999)99-99-99-99");
    $("#FormaCotizador").validate();
  });
</script>
<style type="text/css">
#FormaCotizador label.error {
  display: block;
  background: #FF0000;
  padding:5px;
  color: #FFFFFF;
}
</style>
<form action="index.php" method="POST" class='cmxform' id='FormaCotizador'>
  <input type="hidden" name="option" value="cotizador_qualitas" />
  <input type="hidden" name="paso" value="7" />
  <input type="hidden" name="aseg" value="ana" />
  <input type="hidden" name="id" value="$intIdDatoCotizacion" />
  <input type="hidden" name="tipo" value="$intTipo" />
  
  <table class="TablaReportes">
    <tr>
      <th colspan="4"><h3>Poliza</h3></th>
    </tr>
    <tr>
      <th colspan="4">Datos de la Cotizaci&oacute;n</th>
    </tr>
    <tr>
      <td class="AlinearDerecha">Cotizaci&oacute;n:</td>
      <td>$strNoCotizacion</td>
      <td class="AlinearDerecha">Paquete a Emitir:</td>
      <td>$strPaqEmitir</td>
    </tr>

    <tr>
      <th colspan="4">Asegurado</th>
    </tr>
    <tr>
      <td class="AlinearDerecha">Nombre:</td>
      <td>$strNombre</td>
      <td class="AlinearDerecha">Fecha de Nacimiento:</td>
      <td>
        <input type='hidden' name='datos[aseg][fnac]' id='fnac' value='$strFechaNac' />
        $strFechaNac
      </td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Estado:</td>
      <td>$strEstado</td>
      <td class="AlinearDerecha">Municipio:</td>
      <td>$strMunicipio</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Colonia:</td>
      <td>$strColonia</td>
      <td class="AlinearDerecha">C. P.:</td>
      <td>$strCP</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Calle:</td>
      <td><input type='text' name='datos[aseg][calle]' required /></td>
    </tr>
    <tr>
      <td class="AlinearDerecha">No. Exterior:</td>
      <td><input type='text' name='datos[aseg][num_ext]' required /></td>
      <td class="AlinearDerecha">No. Interior:</td>
      <td><input type='text' name='datos[aseg][num_int]' /></td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Ocupaci&oacute;n:</td>
      <td><input type='text' name='datos[aseg][ocupa]' /></td>
      <td class="AlinearDerecha">RFC:</td>
      <td><input type='text' name='datos[pago][rfc]' value='' required /></td>
    </tr>


    <tr>
      <th colspan="4">Poliza</th>
    </tr>
    <tr>
      <td class="AlinearDerecha">Emision:</td>
      <td>$strFechaEmi</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Vigencia Desde:</td>
      <td>$strVigDesde</td>
      <td class="AlinearDerecha">Vigencia Hasta:</td>
      <td>$strVigHasta</td>
    </tr>


    <tr>
      <th colspan="4">Vehiculo</th>
    </tr>
    <tr>
      <td class="AlinearDerecha">AMIS:</td>
      <td>$strAMIS</td>
      <td class="AlinearDerecha">Marca:</td>
      <td>$strMarca</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Modelo:</td>
      <td>$strDescModelo</td>
      <td class="AlinearDerecha">A&ntilde;o Fabrica:</td>
      <td>$intAnioModelo</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Color:</td>
      <td>$strSelectColor</td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Motor:</td>
      <td><input type='text' name='datos[vehi][motor]' value='' required /></td>
      <td class="AlinearDerecha">Numero Serie:</td>
      <td><input type='text' name='datos[vehi][serie]' value='' required /></td>
    </tr>
    <tr>
      <td class="AlinearDerecha">Placas:</td>
      <td><input type='text' name='datos[vehi][placas]' value='' required /></td>
      <td class="AlinearDerecha">Licencia:</td>
      <td><input type='text' name='datos[vehi][licencia]' value='' required /></td>
    </tr>
    
    <tr>
      <th colspan="3">
        <input type="submit" value="Enviar" />
      </th>
      <th>
        <input type="button" value="Regresar" onclick="document.location.href='index.php?option=cotizador_qualitas&paso=3&id=$intIdDatoCotizacion'" />
      </th>
    </tr>

  </table>
</form>